Urology Coding Alert

Stay on track by following these four examples.

Lithotripsy (50590, Lithotripsy, extracorporeal shock wave) is a common procedure for urologists that has been available for more than 30 years. Common doesn't always mean uncomplicated coding, however, so refresh your knowledge of lithotripsy ins and outs with four Q&As.

Start By Knowing What Happens

Extracorporeal shock wave lithotripsy (ESWL) is a procedure used to destroy calculus (kidney stones) in the kidneys and ureters.  

During this procedure, the physician breaks up kidney stones by directing shock waves through a liquid medium. This can be accomplished two ways:

1. The patient is immersed in liquid medium and a series of shock waves are directed through the liquid to the kidney stone; or

2. The patient is placed on a treatment table and a series of shock waves are directed through a water cushion that is placed against the patient's body at the location of the stone. The treatment table is equipped with video X-ray so the physician can view the process.

After either type of approach, the tiny stone fragments pass harmlessly through the patient's urinary system and are discharged during urination. This process can take a few days or weeks.

Scenario 1: Aborted Lithotripsy Procedure

Question 1: The urologist started an ESWL to fragment a ureteral stone but because of poor sonographic vision he aborted the procedure and changed to fragmenting the stone via ureteroscopic lithotripsy. He documented code 52353. Does this merit modifier 53?

Answer 1: Although the surgeon planned and initiated extracorporeal shockwave lithotripsy (ESWL), the ESWL could not be completed and you should only code for the procedure that accomplished and completed the intended surgery. Therefore, do not report 50590 (Lithotripsy, extracorporeal shock wave). Instead, submit code 52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]) because it represents the procedure that completed the intended surgery.

The case does not justify modifier 53, says Michael Ferragamo MD, FACS, clinical assistant professor of urology, State University of New York. The urologist changed from one procedure to another because of the circumstances, but did not discontinue surgery completely. Modifier 53 represents a complete discontinuation or termination of surgery during that encounter because of a threat to the patient's well-beingor other extenuating circumstances such as equipment failure.

Scenario 2: Stones in Different Locations

Question 2: Our urologist performed an ESWL for a stone in the right ureter and a separate stone in the right renal pelvis. Can I report 50590 and 50590-XS?

Answer 2:  CPT^® coding rules consider the renal pelvis and ipsilateral ureter as separate organs. Therefore, the most correct coding may be 50590 (Lithotripsy, extracorporeal shock wave) and 50590 with modifier XS (Separate structure) appended. That's because you're billing for both procedures on the same side, but in different organs.

Caution: Remember, however, that on occasion, some insurers might deny one of the same CPT^® codes used. According to the situation described above, reporting the same procedure code for two stones in different locations should not be denied, and an appeal certainly would be in order. By contrast, you should only report 50590 once when the urologist performsESWL to treat multiple stones in one organ (either within the ureter or kidney).

Scenario 3: Diagnostic Test Leads to Procedure

Question 3: I bill for an ASC and the surgeon performed a bilateral ureteroscopy then a left ESWL. The ureteroscopy was diagnostic. Fluoroscopic evaluation confirmed a stone in the left lower pole. After these studies the urologist opted to perform an ESWL on the left side. Is the diagnostic ureteroscopy included in the charge for the ESWL or should I billfor the ureteroscopy with modifier 59? I'm thinking 52351 is included in50590.

Answer 3: If the ureteroscopy, an endoscopic procedure, was truly a diagnostic procedure and led to the decision to perform ESWL, you can bill both procedures.

First, report 50590 for the ESWL procedure. Then, report 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy, diagnostic) for the ureteroscopy. Append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to 52351. This indicates that this procedure was in fact diagnostic and responsible for the choice of future therapy, ESWL.

Caveat: If the ureteroscopy was only confirmatory for the presence of the renal calculi initially diagnosed by sonography and did not lead to the treatment choice, just bill 50590 and not for the "scout ureteroscopy," which was really just an examination/review of the operative field.

Scenario 4: Accounting for Fluoroscopy

Question 4:  When my urologist performs an ESWL, is ultrasound guidance and/or fluoroscopy inclusive? If not, can he bill the ultrasound guidance with 76998?

Answer: No, you cannot report 76998 (Ultrasonic guidance, intraoperative) or any other radiology guidance code with 50590 (Lithotripsy, extracorporeal shock wave). The fluoroscopy and ultrasound are included in the extracorporeal shock wave lithotripsy (ESWL) code. They are not separately billable services.